MEDICAID WAIVER TECHNICAL ASSISTANCE CENTER Funded by Virginia Board for People with Disabilities Workshop Presented by Maureen Hollowell, Endependence Center Administered by Endependence Center, Norfolk, VA Fall 2003

? MYTH OR FACT ? 1. I have to need the level of care provided in an institution to qualify for Waiver services. 2. Waiver eligibility for children depends on parent income. 3. Each Waiver offers the same services. 4. I can choose my providers from a list of qualified providers. 5. The administrative appeal process is expensive. 6. All persons with a disability of mental retardation or developmental disability will qualify for the MR or DD Waivers. 7. I can be on a wait list for the DD Waiver or the MR Waiver while I am receiving services through another Waiver.

MAKING CHANGE information is power influence and control rights must be pursued collaboration credibility

MEDICAID MEDICARE SSI SSDI Federal & state program designed to meet the medical needs of certain people who have low income MEDICARE Federal medical benefits primarily for the elderly financed through the Social Security system SSI Supplemental Security Income program provides benefits to people who are elderly or disabled who have limited income and resources. Funded with general tax revenues. SSDI Social Security Disability Insurance provides benefits to people who are disabled. Funds are the FICA social security tax paid on workers’ earnings or earnings of their spouses or parents.

MEDICAID PURPOSE To provide for health and medical care for certain groups of people who have low income HISTORY Medicaid was established with amendments to the Social Security Act in 1965 Medicaid Buy-In FLEXIBILITY States design their own programs within federal standards

MEDICAID IS A JOINT PROGRAM BETWEEN FEDERAL & STATE GOVERNMENTS CENTERS FOR MEDICARE & MEDICAID SERVICES Federal agency CMS Previously HCFA cms.hhs.gov DEPARTMENT FOR MEDICAL ASSISTANCE SERVICES State agency DMAS www.dmas.state.va.us

VIRGINIA MEDICAID DMAS is designated as the single state agency charged with administering Medicaid in Virginia DMAS contracts or has agreements with other entities for most screening, case management, service and billing related activities DMAS is responsible for ensuring that the Medicaid program operates in compliance with state and federal laws and regulations

VIRGINIA’S MEDICAID $ 3,784,312,817 48.45% from state funds Virginia Medicaid budget for fiscal year 2002 $ 3,784,312,817 48.45% from state funds 51.55% from federal funds

STATE PLAN FOR MEDICAL ASSISTANCE Periodically updated to reflect changes Changes must be approved by CMS Details Virginia’s eligibility requirements coverage reimbursement administrative policies To add services requires a change to the State Plan AND Possibly a commitment of dollars from the Virginia General Assembly

MANDATORY MEDICAID SERVICES Inpatient Hospital Services Emergency Hospital Services Outpatient Hospital Services Nursing Facility Care Rural Health Clinics Federally Qualified Health Center Clinic Services Lab and X-Ray Services Physician Services Home Health Service EPSDT Family Planning Nurse-Midwife Services Certified Nurse Practitioner Services Transportation Medicare Premiums (Part A) - Hospital; (Part B) - Supplemental Insurance for Categorically Needy

OPTIONAL Medicaid Services Provided In Virginia Other Clinic Services Skilled Nursing Facility Services for Individuals under 21 years of age Podiatrist Services Optometrist Services Clinical Psychologist Services Home Health PT, OT, and Speech Therapy Prescribed Drugs Case Management Prosthetics Hospice Services Mental Health Services ICF-MR

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Medicaid benefits available to children under the age of 21  Must be eligible for Medicaid  Monitor to prevent health and disability conditions from occurring or worsening, including services to address such conditions  Treatment to “correct or ameliorate conditions,” including maintenance services

EPSDT Immunizations Check ups and lab tests Mental health assessment and treatment Health education Eye exams and glasses Hearing exams and hearing aids & implants Dental services Personal care, nursing services Other needed services, treatment and measures for physical and mental illnesses & conditions

Institutional Placements Hospitals Nursing homes ICFs/MR - Intermediate Care Facility for people with mental retardation or other related conditions institutions of 4 or more beds for people with MR or other related conditions active treatment and rehabilitation regulated by the federal and state governments 24 ICFs/MR in Virginia 5 large “Training Centers,” several hundred beds at each Center 19 smaller ICFs/MR, ranging from 4 to 88 beds

ELIGIBILITY Apply at local Department of Social Services STATE PLAN MEDICAID (Mandatory & Optional Services) Categorical Criteria Disabled or age 65 or older Families with children Pregnant women Recipients of cash assistance Low income Medicare beneficiaries Financial Thresholds Low income and asset guidelines Thresholds vary by category group Parental income/resources DO count for minor children Consideration of exceptionally high medical bills (spend-down) LONG-TERM CARE (Waivers & Institutions) Must Need Long-term Care criteria defined for each Waiver assessment of need required Financial Thresholds 300% of SSI payment limit for one person ($1,656 per month) spend-down for 4 of the Waivers $2000 resource limit Parent income/resources do NOT count regardless of child’s age Services Required All Waiver and State Plan (Mandatory and Optional) services you are eligible for

HIPP Health Insurance Premium Payment program DMAS program Pays health insurance premiums Application must be completed separately from the Medicaid application Application info 800-432-5924

COPAYMENTS Some people may have to pay a copayment for Medicaid services if they do not receive Waiver services. People who receive Home and Community-Based Medicaid Waiver services do not pay copayments for their basic, State Plan Medicaid services. However, some people may have to pay a patient-pay for their Waiver services.

PATIENT-PAY RESPONSIBILITIES People may have to pay for some Waiver services if they have income over $552 per month (except AIDS Waiver which has no patient-pay) Some exceptions for persons who are working (CD-PAS, DD and MR Waivers)

Patient-Pay CD-PAS Waiver, DD Waiver, MR Waiver People may have a patient-pay if income is over $552 a month Can keep earned income up to a total* of 300% of SSI income level if working 20 or more hours/week Can keep earned income up to a total* of 200% of SSI income level if working 8-20 hours/week Still have a patient-pay from unearned income for all Waivers except the AIDS Waiver * total of earned and unearned income Nobody can keep more than $300% of the SSI income level - current federal regs.

AMERICANS WITH DISABILITIES ACT “A public entity shall administer services, programs, and activities in the MOST INTEGRATED SETTING appropriate to the needs of qualified individuals with disabilities.” 28CFR Section 35.130(d)

OLMSTEAD vs. L.C. U.S. SUPREME COURT Tommy Olmstead Commissioner Georgia Dept. of Human Resources Lois Curtis a woman who has mental illness and mental retardation, who was confined to a state psychiatric hospital, wanted to live outside of the hospital

SUPREME COURT “administer services with an even hand” “comprehensive, effectively working plan for placing qualified persons with disabilities in less restrictive settings” “waiting list that moved at a reasonable pace” No concrete date given by the Supreme Court

OLMSTEAD PLAN FOR VIRGINIA Task Force “One Community – Final Report of the Task Force to Develop an Olmstead Plan for Virginia” www.olmsteadVA.com

WHAT ARE HOME & COMMUNITY-BASED MEDICAID WAIVERS? Waivers give States the flexibility to develop and implement alternatives to institutionalization.

WHY WERE HOME & COMMUNITY-BASED WAIVERS ESTABLISHED? Slow the growth of Medicaid spending Institutions are overly restrictive and too highly routine oriented Permit federal Medicaid funds to be used for community services by people who would otherwise be institutionalized

HOW IS A WAIVER DEVELOPED? State develops a Waiver application to be submitted to the federal Centers for Medicare and Medicaid Services (CMS) for approval – Task Forces are usually established by DMAS to assist with development of the applications DMAS develops regulations to implement the Waiver - Public comment is solicited when regulations are proposed The Virginia General Assembly allocates funds for Waiver services – Advocates can educate the General Assembly about the need for funds to provide services Waiver is initially approved by CMS for 3 years and then typically renewed every 5 years – Task Forces are usually established by DMAS to assist with development of the renewal applications

COST EFFECTIVE To receive approval to implement a Waiver, a State Medicaid agency must assure CMS that it will not cost more to provide home and community based services than providing institutional care would cost

Waiver Must be Cost Effective It can be individually cost effective or cost effective in the aggregate Aggregate Cost Effectiveness The average cost to Medicaid of individuals on the Waiver cannot cost more than the average cost to Medicaid of individuals in the comparable institution Individual Cost Effectiveness Cost to Medicaid for the individual in the community can’t exceed the cost in the comparable institution

Medicaid Waivers Virginia has 6 Home and Community Based Care (1915 (c) ) Waivers State Regulations for the Waivers can be found at: http://leg1.state.va.us/000/reg/TOC12030.HTM#C0120 12 VAC-30-120-10 Elderly & Disabled Waiver (E&D Waiver) 12 VAC-30-120-70 Technology Assisted Waiver (Tech Waiver) 12 VAC-30-120-140 AIDS Waiver 12 VAC-30-120-210 Mental Retardation Waiver (MR Waiver) 12 VAC-30-120-490 Consumer-Directed Personal Attendant Services Waiver (CD-PAS Waiver) 12 VAC-30-120-700 Individual and Family Developmental Disabilities Support Waiver (DD Waiver) The reference is to the beginning of each waiver section. For specific waiver sections, refer to the VAC. At DMAS this is on the intranet - Policy - regulations. 7

DIFFERENT INSTITUTION - DIFFERENT WAIVER NURSING HOMES AIDS Elderly and Disabled Consumer Directed -PAS Technology Assisted HOSPITAL AIDS Technology Assisted ICF/MR Mental Retardation Developmental Disabilities

Alternative Institutional Placement There must be an alternate institutional placement for which Medicaid pays The individual who is applying for a Waiver must meet the same criteria that is used for admission to the institution This does not mean that the individual must actually be placed in the institution or make application to an institution In order to understand some of HCFA’s concerns, it is necessary to discuss alternative institutional placement of individuals on the waiver.

SCREENING PROCESS Pre-Admission Screening Teams of the Department of Health & Department of Social Services Elderly and Disabled Waiver CD-PAS Waiver AIDS Waiver Department of Medical Assistance Services Technology Assisted Waiver Community Services Board MR Waiver Department of Health Local Clinics Developmental Disabilities Waiver

LEVEL OF FUNCTIONING (LOF) SURVEY Used for DD and MR Waivers LOF Survey is completed as part of the screening process Determines the level of care needed To receive DD or MR Waiver services, an individual must meet the criteria for admission to an ICF/MR

UNIFORM ASSESSMENT INSTRUMENT (UAI) Used for nursing home placement and the AIDS, CD-PAS, E&D and Tech Waivers Completed as part of screening and assessment Assesses social, physical health and functional abilities Used to gather info for planning and monitoring needs and eligibility

SUPPLEMENT TO SCREENING People who have mental illness, mental retardation or developmental disabilities Initiated by the nursing home preadmission screening team when screening for nursing home placement and the CD-PAS and E&D Waivers Preadmission screening team sends supplement screening request to CSB

PURPOSE OF SUPPLEMENT SCREENING Some people with MR or DD have active treatment needs that are not met by nursing homes or nursing home-related Waivers Determine the person’s need for active treatment that would not be met by nursing homes or nursing home-related Waivers

LEVEL II SUPPLEMENT Specialized Services Services Identified By CSB Responsibility & Entitlement

CASE MANAGEMENT, MR SERVICE SUPPORT COORDINATION, DD SERVICE Ensures development, coordination, implementation, monitoring and modification of the individual’s plan Links the individual with appropriate community resources and supports Coordinates service providers Monitors quality of care

DD WAIVER SUPPORT COORDINATION MR WAIVER CASE MANAGEMENT Individual chooses their Support Coordination organization Various organizations provide Support Coordination services Support Coordination organizations cannot provide other DD Waiver services (except Consumer Directed Services Facilitation) MR WAIVER CASE MANAGEMENT Community Services Boards provide case management services

CONSUMER-DIRECTED SERVICES Freedom, choice and control remaining with the individual, and sometimes their family - what service is needed who will provide it when it will be provided where it will be provided how it will be provided In Virginia, CD services were initiated by Centers for Independent Living and the Virginia Board for People with Disabilities in 1989 Virginia Medicaid Waivers have components of consumer-direction and self-determination, implementation depends on the individual and the case manager or support coordinator

Consumer-Directed Services Individual or family caregiver directs and controls who, how, and when services are provided Virginia offers consumer-directed services in 4 Waivers: Consumer-Directed Personal Attendant Services Waiver (since 1997) - Attendant Developmental Disabilities Waiver (since 2000) - Attendant, Respite Mental Retardation Waiver (since 2001) - Attendant, Respite, Companion AIDS Waiver (began in 2003) – Attendant, Respite

Consumer-Directed Services Individual is the employer of record with the IRS Service Facilitator (SF) writes documentation of need based on information from the individual, monitors the service and provides support as needed to the individual so that the individual can be an employer of their staff SF provides training on recruiting, interviewing and training staff, how to handle difficult situations, how to complete employment paperwork, etc. SF provides list of attendants, companion aides or respite workers and shows how to place an advertisement for attendants, companion aides and respite workers (the list and ads do not have to be used) DMAS (acting as a fiscal agent) and a contractor pays the attendants, companion aides and respite workers on behalf of the individual Currently the number of maximum hours per week of CD-PAS services is 42.

CONSUMER-DIRECTED STAFF QUALIFICATIONS Be 18 years old Possess basic math, reading and writing skills Have the required skills to perform job duties Have a valid Social Security number Submit to a criminal history check Willing to attend training requested by the person receiving Waiver services Willing to register in a CD-staff registry Understand and agree to comply with program requirements

ADDITIONAL REQUIREMENTS OF CONSUMER-DIRECTED STAFF AIDS, DD, & MR WAIVERS Consumer-Directed Staff must receive: TB screening CPR training Annual flu shot

CONSUMER-DIRECTED STAFF Staff (Consumer-Directed employees including attendants, companions, respite workers) Staff may be related to a consumer, but may not be members of the immediate family (parents of minor children, spouses, or legally responsible relatives) Exception: Payments may be made to other staff who are family members when there is objective written documentation as to why there are no other providers available to provide care

CONSUMER INVOLVEMENT Person-centered planning Involve people of your choice in developing your Plan Prepare Plan Choose services Choose providers Decide how & when services will be provided Agree to and monitor Plan Quarterly and Annual Review of Plan Right to appeal areas of disagreement

CONSUMER SERVICES PLAN DD and MR WAIVERS Written document, signed by the consumer Addresses all needs of the individual in all life areas Developed with consumer, providers and others the consumer wants involved CSP will list - services and supports to be provided who will provide the services and supports how often the services and supports will be provided

PREPARING FOR CSP Who will participate in your meeting Develop a list of needed supports & services (be honest & frank) Collect documentation vocational evaluations IEPs school evaluations medical documentation

WHAT ARE YOUR GOALS FOR COMMUNITY AND INDEPENDENT LIVING ?

TO LIVE IN MY OWN APARTMENT (example)

TO LIVE IN MY OWN APARTMENT (example)

HEALTH, SAFETY & WELFARE Adequate services must be provided Additional or different services should be added if needed to protect health, safety and welfare

Individual and Family Developmental Disabilities Support “DD” Waiver Eligibility Criteria “Related Conditions” Waiver Must be 6 years of age and older and meet “related conditions” criteria Cannot have a diagnosis of mental retardation Level of Functioning survey used for screening Call DMAS (804) 786-1465 to request a Request for Screening Form or go to www.dmas.state.va.us Virginia already has a waiver that serves children with developmental disabilities up to age 6. That is the MR Waiver. People on the MR waiver waiting list could have filled all the slots and there would still have been no services for people with developmental disabilities without a diagnosis of MR. Add the AAMR definition One issue that we will need to address is how children transition from the MR Waiver to the DD waiver if there is not a diagnosis of mental retardation at age 6. (1) Cerebral palsy, epilepsy or autism; or (2) Any other condition, other than mental illness, found to be closely related to mental retardation because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of mentally retarded persons, and requires treatment or services similar to those required for these persons. (B) It is manifested before the person reaches age 22. (C) It is likely to continue indefinitely. (D) It results in substantial functional limitations in three or more of the following areas of major life activity: (1) Self-care. (2) Understanding and use of language. (3) Learning. (4) Mobility. (5) Self-direction. (6) Capacity for independent living

RELATED CONDITIONS also referred to as developmental disability Severe chronic disability Attributable to a condition, other than mental illness Manifested before the age of 22 Likely to continue indefinitely Results in substantial limitations in 3 or more areas of major life activity Self-care Understanding and use of language Learning Mobility Self-direction Capacity for independent living

DD Waiver Services Adult companion services (8 hrs per day limit) Assistive technology ($5,000 per year limit) Crisis stabilization (60 day max/year) Environmental modifications ($5,000 per year limit) In-home residential support (not congregate) Day Support Skilled Nursing Supported employment Therapeutic consultation Personal emergency response system (PERS) Family/caregiver training (80 hours max/year) Respite care (CD & agency) Personal assistance services (CD & agency)

DD Waiver Statistics Fiscal Year (FY) 2002 Waiver Expenditures (July 2001 through June 2002) = $1,176,499 Other costs (State Plan services – drugs, doctors’ visits, etc.) = $584,666 124 individuals served in FY 2002 – 323 people enrolled in the DD Waiver as of February 2003 Waiver is cost effective in the aggregate About 40% of the individuals requesting a screening are not eligible for the DD Waiver Wait list is maintained by DMAS Many of the individuals served in FY 2001 will be the same individuals served in FY 2002.

DD Waiver Assuring Waiver Cost-Effectiveness Level 1 55% of Funding Level 2 40% of Funding 5% of Funding Plan of Care $25,000 and Less Plan of Care More than $25,000 Emergencies $5,940,000 $4,320,000 $540,000 231 92

DD Waiver “Start Up” The Lottery Initial 60-day application period (July - August, 2000) gave individuals an equal chance to apply 674 people applied during the initial application period. DMAS had slots for 323 individuals in FY 2002 (July 2001 through June 2002) Therefore, the regulations provided for a “lottery” to determine the order in which the 674 will be served The lottery only applies to the first 674 people who applied Applications from September 1, 2000 forward are first come, first served. About 1200 additional applications received between September 2000 – July 2003 Approximately 450 people on the waiting lists Don’t like to use the term lottery to apply to people and to services that could affect their lives, but it is a term that people understand.

MR Waiver Eligibility Criteria Must have a diagnosis of mental retardation or be under the age of 6 and at developmental risk Children on the MR Waiver who do not have a diagnosis of MR at the age of 6, possible transfer to DD Waiver Screenings are conducted by CSBs Level of Functioning survey is the screening instrument used There is a waiting list for the MR Waiver Screening for all Waivers must be provided without any charge to the individual There is no medically needy program for ICFs/MR, therefore, there is no medically needy program for the MR Waiver.

MR Waiver Services Residential support (group home or individual’s home) Day support and prevocational services Supported employment Personal assistance (CD & agency) Respite care (720 hours max/year) (CD & agency) Assistive technology ($5,000 max/year) Environmental modifications ($5,000 max/year) Skilled nursing services Therapeutic consultation Crisis stabilization (60 days max/year) Adult companion (8 hours max/day) (CD & agency) Personal Emergency Response System (PERS)

MR WAIVER WAITING LISTS Urgent and Non-urgent CSBs and DMHMRSAS maintain Urgent and Non-Urgent lists CSB maintains Planning list CSB provides individual with written notice if placed on a waiting list and if there is a change in status to another list CSB determines who on the Urgent list receives the next available slot Only after all Urgent needs are met statewide will Non-urgent needs be served Slot moves with you to a different town in VA Vacant or new slots are allocated by the CSB unless there is no need in the CSB’s area Non-urgent = meet criteria for the MR Waiver, including needing services within 30 days, but don’t meet Urgent criteria Planning list = need services in the future

URGENT CRITERIA FOR THE MR WAIVER Primary caregiver(s) is/are 55 years or older Living with a primary caregiver who is providing the service voluntarily and without pay and they can’t continue care There is a clear risk of abuse, neglect, or exploitation Primary caregiver has chronic or long term physical or psychiatric condition significantly limiting ability to provide care Individual is aging out of a publicly funded residential placement or otherwise becoming homeless Individual lives with the primary caregiver and there is a risk to the health or safety of the individual, primary caregiver, or other individual living in the home because: Individual’s behavior presents a risk to himself or others OR physical care or medical needs cannot be managed by the primary caregiver even with generic or specialized support arranged or provided by the CSB

MR Waiver Statistics Fiscal Year (FY) 2002 Waiver Expenditures (July 2001 through June 2002) = $197,686,537 Other costs (State Plan services – drugs, doctors’ visits, etc.) = $37,493,074 5,367 individuals served in FY 2002 Waiver is cost effective in the aggregate Approximately 2,100 people on the waiting lists When reporting annual average costs to CMS, the average cost per waiver recipient was $36,300. This was our highest cost waiver.

INDEPENDENCE PLUS WAIVER IPlus Waiver New Waiver being developed by DMAS in collaboration with a task force For people now receiving DD or MR Waivers Would allow for consumer-direction of more Waiver services Would allow different provider rates within a predetermined range Lottery likely to be used to determine first 200 people who would use the IPlus Waiver

Consumer-Directed Personal Attendant Services Waiver (CD-PAS) Eligibility Criteria Can be any age Must meet nursing home criteria Can have a cognitive impairment Screening is the conducted by the Preadmission Screening Team using the UAI Questionnaire used to determine if an individual can independently manage attendants or if assistance with managing care will be needed

RECENT CHANGES TO CD-PAS WAIVER CD-PAS Waiver is now available to children. No longer have to be 18 or older for the CD-PAS Waiver. CD-PAS Waiver is now available to people who are unable to manage their services. Another person can manage their services.

CD-PAS Waiver Statistics Fiscal Year (FY) 2002 Waiver Expenditures (July 2001 through June 2002) = $2,698,064 Other costs (State Plan services – drugs, doctors’ visits, etc.) = $1,047,223 191 individuals served in FY 2002 No waiting list for the CD-PAS Waiver CD-PAS Waiver is individually cost effective When reporting annual average costs to CMS, the average cost per waiver recipient was $11,975

Elderly and Disabled Waiver Criteria Individuals seeking Waiver services are eligible if 65 or older or disabled Must meet nursing facility criteria Individuals are screened by Preadmission Screening Team (DSS social worker, VDH nurse and physician) Screening tool is the Uniform Assessment Instrument (UAI)

Elderly and Disabled Waiver Services Services that are available statewide: Adult Day Health Care Personal Care Services Personal Emergency Response System (PERS) Respite Individuals can receive up to 720 hours of respite per year Personal assistance services can be provided outside of the individual’s home Generally individuals can receive up to 13 hours of personal assistance daily, additional hours can be authorized based on individual circumstances

E&D Waiver Statistics Fiscal Year (FY) 2002 Waiver Expenditures (July 2001 through June 2002) = $90,176,649 Other costs (State Plan services – drugs, doctors’ visits, etc.) = $49,791,342 9,271 individuals served in FY 2002 No waiting list for the E&D Waiver Waiver is cost effective in the aggregate When reporting annual average costs to CMS, the average cost per waiver recipient was $13,500.

COMBINING THE CD-PAS AND E&D WAIVERS The CD-PAS and E&D Waivers will be combined. Waiver will be based on aggregate cost-effectiveness. New Waiver will be called “Long Term Care Options Waiver.”

LONG TERM CARE OPTIONS WAIVER Personal care – both agency and consumer directed – hours based on need. Respite care if there is a primary caregiver – both agency and consumer directed. 720 hours/year. Personal Emergency Response System (includes medication monitoring system). Cannot be a stand-alone service. Adult Day Health Care Earned income allowance will be available in this Waiver. (Working 20 or more hours can keep up to 300% of earned income; working 8-20 hours can keep up to 200% of earned income. Total income cannot exceed 300% of SSI).

Technology Assisted Waiver Criteria Individual may be eligible if she needs both a medical device to compensate for the loss of a vital body function and substantial and ongoing skilled nursing care Screening: UAI is used for adults and Tech Waiver scoring tool is used for children DMAS reviews individual’s private insurance policy for private duty nursing benefits Case management provided by DMAS nurses Different rules for children and adults

Tech Waiver Considerations ADULTS Screening team completes UAI for adults only. DMAS staff follows up to complete the screening for adults Eligible if depends part of day on vent; or requires prolonged intravenous nutrition, drugs, or peritoneal dialysis Cost effectiveness is compared to nursing facility specialized care CHILDREN DMAS staff completes screening for children Eligible if depends part of day on vent; or requires prolonged intravenous nutrition, drugs, or peritoneal dialysis; or daily dependence on other device-based respiratory or nutritional support Cost effectiveness is compared to hospital costs

Tech Waiver Services Services that are available statewide: Private duty nursing Respite care Durable medical equipment Personal care for individuals over 21 years of age Environmental Modifications Most of the funds for this waiver are for private duty nursing.

Tech Waiver Services Limits Environmental modifications and Assistive technology provided if medically necessary and cost effective Respite care has an annual limit of 360 hours per year Private duty nursing has a limit of 16 hours per day, except - individuals under 21 can receive nursing services 24 hours a day during the first 30 days they receive Tech Waiver services

Tech Waiver Statistics Fiscal Year (FY) 2002 Waiver Expenditures (July 2001 through June 2002) = $17,861,853 Other costs (State Plan services – drugs, doctors’ visits, etc.) = $7,994,493 308 individuals served in FY 2002 No waiting list for the Tech Waiver Waiver based on individual cost effectiveness When reporting annual average costs to CMS, the average cost per waiver recipient was $92,200

AIDS Waiver Criteria Individuals are eligible for the AIDS Waiver if they have a diagnosis of AIDS or AIDS-Related Complex and would require nursing facility or hospital care Individuals are screened by a Preadmission Screening Team (DSS social worker, VDH nurse and physician) Screening tool is the Uniform Assessment Instrument (UAI)

AIDS Waiver Services Services that are available statewide: Case management Consumer-Directed Attendant Care Nutritional supplements Private duty nursing Personal care Respite care Individuals can receive up to 720 hours of respite per year Personal assistance services can be provided outside of the individual’s home

AIDS Waiver Statistics Fiscal Year (FY) 2002 Waiver Expenditures (July 2001 through June 2002) = $1,268,876 Other costs (State Plan services – drugs, doctors’ visits, etc.) = $5,910,868 337 individuals served in FY 2002 No waiting list for the AIDS Waiver Waiver is cost effective in the aggregate No patient-pay for the AIDS Waiver The highest “other” cost for this population is pharmacy (approx. $5.4 million). When reporting annual average costs to CMS, the average cost per waiver recipient was $18,800.

BRAIN INJURY WAIVER BEING DEVELOPED DMAS is working with a task force to develop a new Brain Injury Waiver Eligibility, services, providers, and other criteria being discussed by DMAS and the task force Initiation of this new Waiver depends on funding provided by the General Assembly Brain Injury Association of VA, 804-355-5748

DMAS is responsible for - SERVICE PROVIDERS DMAS is responsible for - adequate supply of qualified providers to meet needs of recipients ensuring the capacity and scope of services are available ensuring individuals are able to have “provider choice” enrollment of providers quality of services

ACCESSING PROVIDERS A list of qualified providers for each service in the Consumer Services Plan will be given to you You have the right to choose your providers You have the right to visit, interview and research providers You decide when, where and how you want approved services provided Case Manager/Support Coordinator will assist you in locating and choosing providers Case Manager/Support Coordinator will contact providers for initiation of services You can switch providers if you choose to There are shortages of some providers

MEDICAID APPEALS Fair Hearing Right to challenge decisions and actions regarding Medicaid Decision should be issued by the Hearing Officer within 90 days

RIGHT TO APPEAL WHEN - Application of benefits is denied The agency takes action or proposes to take action which will adversely affect, reduce, or terminate receipt of benefits Request for a specific benefit is denied; in whole or in part The agency does not act with reasonable promptness

What is a reasonable pace? WAITING LISTS DD and MR Waivers are the only Waivers with waiting lists MR Waiver has 2 waiting lists: Urgent and Non-urgent and a planning list DD Waiver has 2 waiting lists: Level I (CSP less than $25,000) and Level II (CSP more than $25,000) No waiting list for the AIDS, E&D, CD-PAS and Tech Waivers Waiting lists are permissible, but waiting lists must move at a reasonable pace What is a reasonable pace?